Low-chloride- versus high-chloride-containing hypertonic solution for the treatment of subarachnoid hemorrhage-related complications: The ACETatE (A low ChloriE hyperTonic solution for brain Edema) randomized trial

Serum sodium concentration predicting mortality in patients with aneurysmal subarachnoid hemorrhage

BACKGROUND

To date, inconsistent evidence exists on the role of hypernatremia in patients with aneurysmal subarachnoid hemorrhage (aSAH) who underwent surgical clipping. We aimed to investigate the association between serum sodium and mortality in these patients.

METHODS

A cohort study was performed to include adult patients with aSAH who underwent surgical clipping in a university hospital. The primary outcome was follow-up mortality. Propensity score matching (PSM) was used for matching patients' baseline characteristics. Net reclassification improvement (NRI), and integrated discrimination improvement (IDI) were calculated to assess and compare the reclassification and discrimination capacity of different models. Trends in serum sodium over time were detected by the ordinary least squares model.

RESULTS

Of 618 aSAH patients with surgical clipping during the study period, normal serum sodium was observed in 467 patients (75.6 %), and admission hypernatremia was noted in 151 patients (24.4 %). After adjustment with multivariate regression analysis, patients with hypernatremia had significantly higher odds for follow-up mortality (aOR: 2.86, 95 % CI: 1.54 to 5.30; P = 0.001). PSM analysis observed similar results (aOR: 2.38, 95 % CI: 1.29 to 4.55; P = 0.009). The incorporation of serum sodium during hospitalization markedly enhanced the IDI (P < 0.001) and NRI (P < 0.001) for the prediction of mortality.

CONCLUSIONS

In conclusion, the findings from this cohort study of aSAH patients with surgical clipping indicated that serum sodium can be an independent predictive factor of all-cause mortality, and inferior sequelae in aSAH patients. These findings endorsed the importance of managing hypernatremia and monitoring serum sodium in patients with aSAH.

Which Intravenous Isotonic Fluid Offers Better Outcomes for Patients with a Brain Injury?

Administering intravenous fluids is a common therapy for critically ill patients. Isotonic crystalloid solutions, such as saline or balanced solutions, are frequently used for intravenous fluid therapy. The choice between saline or a balanced crystalloid has been a significant question in critical care medicine. Recent large randomized controlled trials (RCTs) have investigated whether balanced crystalloids yield better outcomes in general or specific critical care populations, and many of them have confirmed this hypothesis. Although the broad eligibility criteria of these RCTs suggest applicability to neurocritical care patients, it is important to discuss whether using balanced crystalloids, as opposed to saline, would benefit patients who primarily have neurological disorders or diseases. This review considers the relevance of this question, weighs the pros and cons of the two fluid types, examines available data, and anticipates results from ongoing RCTs to guide clinicians in selecting the optimal fluid for patients with brain injury.

Factors Associated with the Onset of Acute Kidney Injury Following Subarachnoid Hemorrhage

BACKGROUND

Acute kidney injury (AKI) is a complication often observed in critically ill patients, indicating a worsening prognosis. However, factors predicting AKI in subarachnoid hemorrhage (SAH) patients are unclear. This study aims to elucidate the predictors of AKI occurrence.

METHODS

All patients with SAH admitted to the intensive care unit between 2013 and 2019 were included. Patients with very severe SAH who are unsuitable to receive aggressive treatment, those who previously received a contrast medium at another medical institution within 24 hours before admission, and those on maintenance dialysis were excluded. We retrospectively examined blood tests conducted upon admission, oral medications administered, and the total amount of contrast medium used after initiating treatment to investigate their association with AKI occurrence.

RESULTS

Of the 254 SAH patients treated during the relevant period, 195 (median age 64 years, 72 males) met the inclusion/exclusion criteria, and 32 patients (16.3%) developed AKI. When multivariate analysis was performed using sex, uric acid level, and hemoglobin, which obtained P < 0.01 in the univariate analysis, as variables, only uric acid level was found as an independent predictor of AKI (odds ratio, 1.501; 95% confidence interval, 1.109-2.033, P value of 0.009). There was no difference in the occurrence of AKI between survivors and nonsurvivors (12/163 vs. 2/32, P = 0.824).

CONCLUSIONS

AKI occurred in 16.3% of the patients with SAH. Patients who developed AKI had significantly higher uric acid levels. SAH with high uric acid levels warrants attention for AKI.

Should Hypertonic Saline Be Considered for the Treatment of Intracranial Hypertension? A Review of Current Evidence and Clinical Practices

Intracranial hypertension (IH) is a critical neurological emergency that requires prompt intervention because failure to treat it properly can lead to severe outcomes, including secondary brain injury. Traditionally, mannitol (MNT) has been the cornerstone of hyperosmolar therapy. However, the use of hypertonic saline (HTS) has become increasingly important because of its unique advantages. Both HTS and MNT effectively reduce intracranial pressure by creating an osmotic gradient that draws fluid from brain tissue. However, unlike MNT, HTS does not induce diuresis or significantly lower blood pressure, making it more favorable for maintaining cerebral perfusion. Additionally, HTS does not cause rebound edema and carries a lower risk of renal injury than MNT. However, it is important to note that the use of HTS comes with potential risks, such as hypernatremia, hyperchloremia, and fluid overload. Due to its unique properties, HTS is a crucial agent in the management of IH, and understanding its appropriate use is essential to optimize patient outcomes.

Iatrogenic hyperchloremia: An overview in hospitalized patients for pharmacists

PURPOSE

The purpose of this therapeutic update is to provide pharmacists with a general overview of the pathophysiology of hyperchloremia and describe strategies to help prevent development of this electrolyte abnormality in hospitalized patients.

SUMMARY

Hyperchloremia is an electrolyte abnormality associated with an increased incidence of acute kidney injury and metabolic acidosis. Intravenous (IV) fluids utilized for volume resuscitation, medication diluents, and total parental nutrition all may contribute to the development of hyperchloremia. Current evidence suggests that administration of balanced crystalloids for either fluid resuscitation or maintenance fluids may impact serum chloride levels and patient outcomes. In multiple randomized controlled trials, administering balanced crystalloids for fluid resuscitation in critically ill patient populations did not decrease mortality. However, further analyses of subpopulations within these trials have demonstrated that patients with sepsis may benefit from receiving balanced crystalloids for initial fluid resuscitation. Results from several small studies suggest that altering the composition of these IV fluids may help prevent development of hyperchloremia.

CONCLUSION

Management of hyperchloremia is preventative in nature and can be mitigated through management of resuscitation fluids, medication diluents, and total parenteral nutrition. Inpatient pharmacists should be aware of the potential risk of fluid-associated hyperchloremia and assist with optimal fluid management to prevent and manage hyperchloremia.

Acute kidney injury in neurocritical care

Approximately 20% of patients with acute brain injury (ABI) also experience acute kidney injury (AKI), which worsens their outcomes. The metabolic and inflammatory changes associated with AKI likely contribute to prolonged brain injury and edema. As a result, recognizing its presence is important for effectively managing ABI and its sequelae. This review discusses the occurrence and effects of AKI in critically ill adults with neurological conditions, outlines potential mechanisms connecting AKI and ABI progression, and highlights AKI management principles. Tailored approaches include optimizing blood pressure, managing intracranial pressure, adjusting medication dosages, and assessing the type of administered fluids. Preventive measures include avoiding nephrotoxic drugs, improving hemodynamic and fluid balance, and addressing coexisting AKI syndromes. ABI patients undergoing renal replacement therapy (RRT) are more susceptible to neurological complications. RRT can negatively impact cerebral blood flow, intracranial pressure, and brain tissue oxygenation, with effects tied to specific RRT methods. Continuous RRT is favored for better hemodynamic stability and lower risk of dialysis disequilibrium syndrome. Potential RRT modifications for ABI patients include adjusted dialysate and blood flow rates, osmotherapy, and alternate anticoagulation methods. Future research should explore whether these strategies enhance outcomes and if using novel AKI biomarkers can mitigate AKI-related complications in ABI patients.

Kidney Dysfunction After Traumatic Brain Injury: Pathophysiology and General Management

Traumatic brain injury (TBI) remains a major cause of mortality and morbidity, and almost half of these patients are admitted to the intensive care unit. Of those, 10% develop acute kidney injury (AKI) and 2% even need kidney replacement therapy (KRT). Although clinical trials in patients with TBI who have AKI are lacking, some general principles in this population may apply. The present review is an overview on the epidemiology and pathophysiology of AKI in patients with TBI admitted to the intensive care unit who are at risk for or who have developed AKI. A cornerstone in severe TBI management is preventing secondary brain damage, in which reducing the intracranial pressure (ICP) and optimizing the cerebral perfusion pressure (CPP) remain important therapeutic targets. To treat episodes of elevated ICP, osmolar agents such as mannitol and hypertonic saline are frequently administered. Although we are currently awaiting the results of a prospective randomized controlled trial that compares both agents, it is important to realize that both agents have been associated with an increased risk of developing AKI which is probably higher for mannitol compared with hypertonic saline. For the brain, as well as for the kidney, targeting an adequate perfusion pressure is important. Hemodynamic management based on the combined use of intravascular fluids and vasopressors is ideally guided by hemodynamic monitoring. Hypotonic albumin or crystalloid resuscitation solutions may increase the risk of brain edema, and saline-based solutions are frequently used but have a risk of hyperchloremia, which might jeopardize kidney function. In patients at risk, frequent assessment of serum chloride might be advised. Maintenance of an adequate CPP involves the optimization of circulating blood volume, often combined with vasopressor agents. Whether individualized CPP targets based on cerebrovascular autoregulation monitoring are beneficial need to be further investigated. Interestingly, such individualized perfusion targets are also under investigation in patients as a strategy to mitigate the risk for AKI in patients with chronic hypertension. In the small proportion of patients with TBI who need KRT, continuous techniques are advised based on pathophysiology and expert opinion. The need for KRT is associated with a higher risk of intracranial hypertension, especially if osmolar clearance occurs fast, which can even occur in continuous techniques. Precise ICP and CPP monitoring is mandatory, especially at the initiation of KRT.

Hypomagnesemia Is Associated with the Acute Kidney Injury in Traumatic Brain Injury Patients: A Pilot Study

Background: Acute kidney injury (AKI) commonly develops among traumatic brain injury (TBI) patients and causes poorer outcomes. We perform this study to explore the relationship between serum magnesium and the risk of AKI among TBI. Methods: TBI patients recorded in the Medical Information Mart for Intensive Care-III database were eligible for this research. The restricted cubic spline (RCS) was utilized to fit the correlation between serum magnesium level and the AKI. Univariate and subsequent multivariate logistic regression analysis were utilized to explore risk factors of AKI and confirmed the correlation between serum magnesium and AKI. Results: The incidence of AKI in included TBI was 21.0%. The RCS showed that the correlation between magnesium level and risk of AKI was U-shaped. Compared with patients whose magnesium level was between 1.5 and 2.0 mg/dL, those with a magnesium level of <1.5 mg/dL or >2.0 mg/dL had a higher incidence of AKI. Multivariate logistic regression confirmed age, chronic renal disease, ISS, serum creatinine, vasopressor, mechanical ventilation, and serum magnesium <1.5 mg/dL were independently related with the AKI in TBI. Conclusion: Abnormal low serum magnesium level is correlated with AKI development in TBI patients. Physicians should pay attention on renal function of TBI patients especially those with hypomagnesemia.

Acute kidney injury in neurocritical patients: a retrospective cohort study

BACKGROUND /OBJECTIVE

Acute kidney injury (AKI) is a significant complication in critical care units (CCU). Non-neurological complications such as AKI are an independent predictor of poor clinical outcomes, with an increase in morbidity and mortality, financial costs, and worse functional recovery. This work aims to estimate the incidence of AKI and evaluate the risk factors and complications of AKI in neurocritical patients hospitalized in the CCU.

METHODS

A retrospective cohort study was conducted. Patients admitted to the neurocritical care unit between 2016 and 2018 with a stay longer than 48 h were retrospectively analyzed in regard to the incidence, risk factors, and outcomes of AKI.

RESULTS

The study population comprised 213 neurocritical patients. The incidence of AKI was 23.5%, with 58% KDIGO 1 and 2% requiring renal replacement therapy. AKI was an independent predictor of prolonged use of mechanical ventilation, cerebral edema, and mortality. Cerebral edema [OR 4.40 (95% CI 1.98-9.75) p < 0.001] and a change in chloride levels greater than 4 mmol/L at 48 h (OR 2.44 (95% CI 1.10-5.37) p = 0.027) were risk factors for developing AKI in the first 14 days of hospitalization.

CONCLUSION

There is a high incidence of AKI in neurocritical patients; it is associated with worse clinical outcomes regardless of the CCU admission etiology or AKI severity.

Utility of frailty as a predictor of acute kidney injury in patients with aneurysmal subarachnoid hemorrhage

INTRODUCTION

Acute kidney injury (AKI) is associated with poor outcome in aneurysmal subarachnoid hemorrhage patients (aSAH). Frailty has recently been demonstrated to correlate with elevated mortality and morbidity; its impact on predicting AKI and mortality in aSAH patients has not been investigated.

OBJECTIVE

Evaluating risk factors and predictors for AKI in aSAH patients.

METHODS

aSAH patients from a single-center's prospectively maintained database were retrospectively evaluated for development of AKI within 14 days of admission. Baseline demographic and clinical characteristics were collected. The effect of frailty and other risk factors were evaluated.

RESULTS

Of 213 aSAH patients, 53 (33.1%) were frail and 12 (5.6%) developed AKI. Admission serum creatinine (sCr) and peak sCr within 48 h were higher in frail patients. AKI patients showed a trend towards higher frailty. Mortality was significantly higher in AKI than non-AKI aSAH patients. Frailty was a poor predictor of AKI when controlling for Hunt and Hess (HH) grade or age. HH grade ≥ 4 strongly predicted AKI when controlling for frailty.

CONCLUSION

AKI in aSAH patients carries a poor prognosis. The HH grade appears to have superior utility as a predictor of AKI in aSAH patients than mFI.

Association of hyperchloremia and acute kidney injury in pediatric patients with moderate and severe traumatic brain injury

PURPOSE

Acute kidney injury (AKI) is an established complication of adult traumatic brain injury (TBI) and known risk factor for mortality. Evidence demonstrates an association between hyperchloremia and AKI in critically ill adults but studies in children are scarce. Given frequent use of hypertonic saline in the management of pediatric TBI, we believe the incidence of hyperchloremia will be high and hypothesize that it will be associated with development of AKI.

METHODS

Single-center retrospective cohort study was completed at an urban, level 1 pediatric trauma center. Children > 40 weeks corrected gestational age and < 21 years of age with moderate or severe TBI (presenting GCS < 13) admitted between January 2016 and December 2021 were included. Primary study outcome was presence of AKI (defined by pediatric Kidney Disease: Improving Global Outcomes criteria) within 7 days of hospitalization and compared between patients with and without hyperchloremia (serum chloride ≥ 110 mEq/L).

RESULTS

Fifty-two children were included. Mean age was 5.75 (S.D. 5.4) years; 60% were male (31/52); and mean presenting GCS was 6 (S.D. 2.9). Thirty-seven patients (71%) developed hyperchloremia with a mean peak chloride of 125 (S.D. 12.0) mEq/L and mean difference between peak and presenting chloride of 16 (S.D. 12.7) mEq/L. Twenty-three patients (44%) developed AKI; of those with hyperchloremia, 62% (23/37) developed AKI, while among those without hyperchloremia, 0% (0/15) developed AKI (difference 62%, 95% CI 42-82%, p < 0.001). Attributable risk of hyperchloremia leading to AKI was 62.2 (95% CI 46.5-77.8, p = 0.0015).

CONCLUSION

Hyperchloremia is common in the management of pediatric TBI and is associated with development of AKI. Risk appears to be associated with both the height of serum chloride and duration of hyperchloremia.

Early Hyperchloremia and Outcomes After Severe Traumatic Brain Injury: Analysis of Resuscitation Outcomes Consortium Hypertonic Saline Trial

To investigate the effect of the occurrence of early hyperchloremia on death or severe disability at 180 days in patients with severe traumatic brain injury (TBI).

DESIGN

Post hoc analysis of Resuscitation Outcomes Consortium Hypertonic Saline (ROC HS)-TBI trial.

SETTING

A total of 114 North American emergency medical services agencies in the ROC.

PATIENTS

A total of 991 patients with severe TBI and Glasgow Coma Scale score of less than or equal to 8.

INTERVENTIONS

Prehospital resuscitation with single IV dose (250 cc) of 7.5% saline in 6% dextran-70, 7.5% saline (no dextran), or crystalloid.

MEASUREMENTS AND MAIN RESULTS

Patients with increased serum chloride concentrations (110 mmol/L or greater) 24 hours after randomization were identified. Hyperchloremia was graded into one or greater than or equal to 2 occurrences in the first 24 hours. Logistic regression analyses were performed to determine the effects of hyperchloremia on: 1) death or severe disability at 180 days and 2) death within 180 days after adjusting for confounders. Compared with patients without hyperchloremia, patients with greater than or equal to 2 occurrences of hyperchloremia had significantly higher odds of death or severe disability at 180 days (odds ratio [OR], 1.81; 95% CI, 1.19-2.75) and death within 180 days (OR, 1.89; 95% CI, 1.14-3.08) after adjustment for confounders. However, the total volume of fluids administered during the first 24 hours was an independent predictor of death within 180 days; therefore, after adding an interaction term between the total volume of fluids administered during the first 24 hours and greater than or equal to 2 occurrences of hyperchloremia, patients with greater than or equal to 2 occurrences of hyperchloremia had significantly higher odds of death within 180 days (OR, 2.35; 95% CI, 1.21-4.61 d) but not of composite outcome of death or severe disability at 180 days.

CONCLUSIONS

After modifying for the effect of the total volume of fluids administered during the first 24 hours, multiple occurrences of hyperchloremia in the first 24 hours were associated with higher odds of death within 180 days in patients with severe TBI.

A Machine Learning Approach for the Prediction of Severe Acute Kidney Injury Following Traumatic Brain Injury

BACKGROUND

Acute kidney injury (AKI), a prevalent non-neurological complication following traumatic brain injury (TBI), is a major clinical issue with an unfavorable prognosis. This study aimed to develop and validate machine learning models to predict severe AKI (stage 3 or greater) incidence in patients with TBI.

METHODS

A retrospective cohort study was conducted by using two public databases: the Medical Information Mart for Intensive Care IV (MIMIC)-IV and the eICU Collaborative Research Database (eICU-CRD). Recursive feature elimination was used to select candidate predictors obtained within 24 h of intensive care unit admission. The area under the curve and decision curve analysis curves were used to determine the discriminatory ability. On the other hand, the calibration curve was employed to evaluate the calibrated performance of the newly developed machine learning models.

RESULTS

In the MIMIC-IV database, there were 808 patients diagnosed with moderate and severe TBI (msTBI) (msTBI is defined as Glasgow Coma Score < 12). Of these, 60 (7.43%) patients experienced severe AKI. External validation in the eICU-CRD indicated that the random forest (RF) model had the highest area under the curve of 0.819 (95% confidence interval 0.783-0.851). Furthermore, in the calibration curve, the RF model was well calibrated (P = 0.795).

CONCLUSIONS

In this study, the RF model demonstrated better discrimination in predicting severe AKI than other models. An online calculator could facilitate its application, potentially improving the early detection of severe AKI and subsequently improving the clinical outcomes among patients with msTBI.

Early hyperchloremia and outcomes after acute ischemic stroke

OBJECTIVE

Based on the relationship between hyperchloremia and mortality in critically ill patients, we investigated the effect of early hyperchloremia on 90-day outcomes in acute ischemic stroke patients.

MATERIALS AND METHODS

Acute ischemic stroke patients recruited within 5 h of symptom onset were analyzed. Hyperchloremia (defined as 110 mmol/L or greater) at either baseline, or 24, or 48 h after randomization was identified and classified as one occurrence or two or more occurrences. Logistic regression analyses were performed to determine the effects of hyperchloremia on: favorable outcomes (defined by a National Institutes of Health Stroke Scale and/or modified Rankin scale scores of 0-1) at 90-day, death or disability at 90-day, and death within 90-day after accounting for potential confounders.

RESULTS

Among the total of 1275 patients, one and two or more occurrence of hyperchloremia within 48 h were seen in 191 patients and 108 patients, respectively. Compared with patients without hyperchloremia, patients with two or more occurrences of hyperchloremia at significantly higher odds of lack of favorable outcomes (odds ratio 3.0, 95% confidence interval 1.8-5.1) and death or disability (odds ratio 2.6, 95% confidence interval 1.6-4.1) at 90-day after adjustment for age, National Institutes of Health Stroke Scale score strata (6-9, 10-19, ≥ 20), study intervention, initial SBP, and intra-arterial treatment.

CONCLUSIONS

The independent association between sustained hyperchloremia and lack of favorable outcomes at 90-day suggest that avoidance of hyperchloremia may reduce the rate of lack of favorable outcomes and death or disability in patients with acute ischemic stroke.

Increase in chloride from baseline is independently associated with mortality in intracerebral hemorrhage patients admitted to intensive care unit: A retrospective study

Background

Hyperchloremia is associated with increased mortality in critically ill patients. The objective of this study was to investigate the association between increased chloride levels and mortality outcomes in intracerebral hemorrhage (ICH) patients admitted to the intensive care unit (ICU).

Methods

We performed a retrospective study of all patients diagnosed with ICH and included in the Medical Information Mart for Intensive Care (MIMIC-Ⅲ) from 2001 to 2012. Inclusion criteria were the first diagnosis of ICH, ICU length of stay (LOS) over 72 h, and not receiving hypertonic saline treatment. Serum chloride perturbation within 72 h of admission was evaluated as a predictor of outcomes. The increase in chloride from baseline was dichotomized based on an increase in chloride in 72 h (≤5 mmol/L or >5 mmol/L). The primary outcome was 90-day mortality.

Results

A total of 376 patients (54.5% male, median age 70 years, interquartile range:58-79 years) were included. The overall 90-day mortality was 32.2% (n=121), in-hospital mortality was 25.8% (n=97), and Day 2 acute kidney injury (AKI) occurred in 29.0% (n=109) of patients. The prevalence of hyperchloremia on admission, during the first 72 h, and an increase in chloride (>5 mmol/L) were 8.8%, 39.4%, and 42.8%, respectively. After adjusting for confounders, the hazard ratio of increase in chloride (>5 mmol/L) was 1.66 (95% confidence interval:1.05-2.64, P=0.031). An increase in chloride (>5 mmol/L) was associated with a higher odds ratio for 90-day mortality in both the AKI and non-AKI groups.

Conclusions

An increase in chloride from baseline is common in adult patients with ICH admitted to ICU. The increase is significantly associated with elevated mortality. These results support the significance of diligently monitoring chloride levels in these patients.

Experimenting with modifications to consent forms in comparative effectiveness research: understanding the impact of language about financial implications and key information

Background

Informed consent forms are intended to facilitate research enrollment decisions. However, the technical language in institutional templates can be unfamiliar and confusing for decision-makers. Standardized language describing financial implications of participation, namely compensation for injury and costs of care associated with participating, can be complex and could be a deterrent for potential participants. This standardized language may also be misleading in the context of comparative effectiveness trials of standard care interventions, in which costs and risk of injury associated with participating may not differ from regular medical care. In addition, the revised U.S. Common Rule contains a new requirement to present key information upfront; the impact of how this requirement is operationalized on comprehension and likelihood of enrollment for a given study is unknown.

Methods

Two online surveys assessed the impact of (1) changes to compensation for injury language (standard vs. tailored language form) and (2) changes to the key information page (using the tailored compensation language form with standard key information vs. modified key information vs. modified key information plus financial information) on both likelihood of enrollment in and understanding of a hypothetical comparative effectiveness trial.

Results

Likelihood of enrolling was not observed to be different between the standard and tailored language forms in Study 1 (73 vs. 75%; p = 0.6); however, the tailored language group had a higher frequency of understanding the compensation for injury process specific to the trial (25 vs. 51%; p < 0.0001). Modifications to the key information sheet in Study 2 did not affect likelihood of enrolling (88 vs. 85 vs. 85%; p = 0.6); however, understanding of randomization differed by form (44 vs. 59 vs. 46%; p = 0.002).

Conclusions

These findings suggest that refining consent forms to clarify key information and tailoring compensation for injury language to the nature of the study, especially in the context of comparative effectiveness trials, may help to improve study comprehension but may not impact enrollment.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12910-021-00736-x.

A nomogram based on serum cystatin C for predicting acute kidney injury in patients with traumatic brain injury

BACKGROUND

Acute kidney injury (AKI) is a common complication in traumatic brain injury (TBI) patients and is associated with unfavorable outcome of these patients. We designed this study to explore the value of serum cystatin C, an indicator of renal function, on predicting AKI after suffering TBI.

METHODS

Patients confirmed with TBI and hospitalized in the West China Hospital of Sichuan University between January 2015 and December 2019 were included. Patients were divided into two groups according to occurrence of AKI. Univariate and multivariate logistic regression analyses were sequentially utilized to find risk factors of AKI in included TBI patients. Nomogram composed of discovered risk factors for predicting AKI was constructed. Receiver operating characteristics (ROC) curves were drawn and area under the ROC curve (AUC) were calculated to evaluate the predictive value of cystatin C alone and the constructed nomogram.

RESULTS

Among 234 included TBI patients, 55 were divided into AKI group. AKI group had shorter length of stay (p < 0.001) and higher in-hospital mortality (p < 0.001). Multivariate logistic regression analysis showed absolute lymphocyte count (p = 0.034), serum creatinine (p < 0.001), serum cystatin C (p = 0.017) and transfusion of red blood cell (p = 0.005) were independently associated with development of AKI after TBI. While hypertonic saline use was not associated with the development of AKI (p = 0.067). The AUC of single cystatin C and predictive nomogram were 0.804 and 0.925, respectively.

CONCLUSION

Higher serum cystatin C is associated with development of AKI in TBI patients. Predictive nomogram incorporating cystatin C is beneficial for physicians to evaluate possibilities of AKI and consequently adjust treatment strategies to avoid occurrence of AKI.

Incidence and Burden of Acute Kidney Injury among Traumatic Brain-Injury Patients

Background

Acute kidney injury (AKI) has been occurs commonly in the clinical management of traumatic brain injury (TBI) patients and is correlated with outcomes in these patients. We designed this study to investigate the incidence, duration, stage, and burden of AKI among these patients.

Methods

A total of 419 TBI inpatients at our hospital were included in the study. We calculated the AKI burden, reflecting both stage and duration, and then analyzed associations among AKI occurrence, highest AKI stage, AKI duration, AKI burden, and outcomes with logistic regression analysis.

Results

Incidence of AKI among TBI patients was 19.8%. These patients’ AKIs occurred mainly on the first day from admission (10.74%), and mostly developed stage 1 AKI (9.79%). Modes of AKI duration and burden in those with AKI were both 1. Multivariate logistic regression showed AKI occurrence (OR 3.792, p=0.004) and the highest AKI stage (OR 3.122, p<0.001) was significantly associated with mortality. Neither AKI duration (OR 1.083, p=0.206) nor AKI burden (OR 1.062, p=0.171) were associated with mortality. Incorporating AKI occurrence or highest AKI stage did not improve the predictive value of the constructed prognostic model.

Conclusion

The high-incidence period of AKI in TBI patients was the first 3 days after admission. AKI occurrence and highest AKI stage were associated with mortality, while AKI duration and AKI burden were not associated with mortality.

Acute Kidney Injury at the Neurocritical Care Unit

Neurocritical care has advanced substantially in recent decades, allowing doctors to treat patients with more complicated conditions who require a multidisciplinary approach to achieve better clinical outcomes. In neurocritical patients, nonneurological complications such as acute kidney injury (AKI) are independent predictors of worse clinical outcomes. Different research groups have reported an AKI incidence of 11.6% and an incidence of stage 3 AKI, according to the Kidney Disease: Improving Global Outcomes, that requires dialysis of 3% to 12% in neurocritical patients. These patients tend to be younger, have less comorbidity, and have a different risk profile, given the diagnostic and therapeutic procedures they undergo. Trauma-induced AKI, sepsis, sympathetic overstimulation, tubular epitheliopathy, hyperchloremia, use of nephrotoxic drugs, and renal hypoperfusion are some of the causes of AKI in neurocritical patients. AKI is the result of a sum of events, although the mechanisms underlying many of them remain uncertain; however, two important causes that merit mention are direct alteration of the physiological brain-kidney connection and exposure to injury as a result of the specific medical management and well-established therapies that neurocritical patients are subjected to. This review will focus on AKI in neurocritical care patients. Specifically, it will discuss its epidemiology, causes, associated mechanisms, and relationship to the brain-kidney axis. Additionally, the use and risks of extracorporeal therapies in this group of patients will be reviewed.

Aneurysmal Subarachnoid Hemorrhage: Trends, Outcomes, and Predictions From a 15-Year Perspective of a Single Neurocritical Care Unit

BACKGROUND

Aneurysmal subarachnoid hemorrhage (aSAH) is associated with disproportionally high mortality and long-term neurological sequelae. Management of patients with aSAH has changed markedly over the years, leading to improvements in outcome.

OBJECTIVE

To describe trends in aSAH care and outcome in a high-volume single center 15-yr cohort.

METHODS

All new admissions diagnosed with subarachnoid hemorrhage (SAH) to our tertiary neuro-intensive care unit between 2002 and 2016 were reviewed. Trend analysis was performed to assess temporal changes and a step-wise regression analysis was done to identify factors associated with outcomes.

RESULTS

Out of 3970 admissions of patients with SAH, 2475 patients proved to have a ruptured intracranial aneurysm. Over the years of the study, patient acuity increased by Hunt & Hess (H&H) grade and related complications. Endovascular therapies became more prevalent over the years, and were correlated with better outcome. Functional outcome overall improved, yet the main effect was noted in the low- and intermediate-grade patients. Several parameters were associated with poor functional outcome, including long-term mechanical ventilation (odds ratio 11.99, CI 95% [7.15-20.63]), acute kidney injury (3.55 [1.64-8.24]), pneumonia (2.89 [1.89-4.42]), hydrocephalus (1.80 [1.24-2.63]) diabetes mellitus (1.71 [1.04-2.84]), seizures (1.69 [1.07-2.70], H&H (1.67 [1.45-1.94]), and age (1.06 [1.05-1.07]), while endovascular approach to treat the aneurysm, compared with clip-ligation, had a positive effect (0.35 [0.25-0.48]).

CONCLUSION

This large, single referral center, retrospective analysis reveals important trends in the treatment of aSAH. It also demonstrates that despite improvement in functional outcome over the years, systemic complications remain a significant risk factor for poor prognosis. The historic H&H determination of outcome is less valid with today's improved care.

The authors' response

In response to comments raised, we acknowledge the shortcomings of our study. It is a small study. However, it is a pilot study, which is not meant to create generalizable data, rather to explore new potential directions. To this end, our conclusions were clearly supported by the results. We demonstrated that administration of 16.4% NaCl/Na-acetate solution was feasible, safe, and was associated with lower rates of AKI. We share the call that large RCTs are required to follow this pilot study and hope that our data will stimulate the ongoing discussion regarding the role of chloride in AKI mechanism.

Acute kidney injury after aneurysmal subarachnoid hemorrhage: is chloride really responsible?

Sadan et al. find an association between acute kidney injury and high chloride containing a hypertonic solution. Recent large prospective non-randomized studies bring conflicting results on the relationship between chloride and acute kidney injury. We discuss Sadan et al.'s results according to the recent literature.